| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,844 |
827 |
$106K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,480 |
665 |
$74K |
| D1110 |
Prophylaxis - adult |
2,081 |
2,032 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
2,535 |
2,468 |
$54K |
| D1206 |
Topical application of fluoride varnish |
3,657 |
3,531 |
$49K |
| D0274 |
Bitewings - four radiographic images |
2,699 |
2,607 |
$33K |
| D0330 |
Panoramic radiographic image |
866 |
829 |
$32K |
| D9630 |
|
1,656 |
1,577 |
$25K |
| D0220 |
Intraoral - periapical first radiographic image |
3,132 |
2,980 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
668 |
634 |
$22K |
| D1120 |
Prophylaxis - child |
915 |
889 |
$19K |
| D1351 |
Sealant - per tooth |
382 |
104 |
$11K |
| D1999 |
|
1,112 |
862 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,961 |
2,680 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
76 |
$2K |
| D4346 |
|
14 |
13 |
$320.00 |
| D0350 |
|
593 |
565 |
$0.00 |